Hemodialysis is a procedure in which a machine removes waste from the blood when the kidneys are unable to do so. In this procedure, the machine takes over the function of the kidneys. It is important to note that hemodialysis is not an exact science, it has limitations, and can have side effects. It’s quick, but it’s not perfect.
In this process, wastes and other substances in the blood are removed from one side of a membrane to the other side by diffusion, osmosis, and ultrafiltration. The membrane can be made out of different materials such as cellulose acetate, polysulfone or nylon.
Hemodialysis patients can be one of the most difficult patients to treat and diagnose even in the prehospital setting. Renal failure alone can bring on some deadly consequences to the patient; let alone all of the different organs affected by the disease. Electrolyte abnormalities, vascular access issues and acidosis are just the tip of the ice burg you may find yourself managing. In this article I’ll point out key lessons I’ve picked up from dealing with dialysis patients.
Patient 1: You respond to a diabetic problem at 6am. Upon arrival you have a 28 year old female supine on the floor of a dirty apartment. Her roommate came home to from her night shift to find the patient on the kitchen floor. The patient is cold clammy and diaphoretic. When assessing the patients glucose the meter only reads “low”. After assessing the extremities and talking with the roommate you find out the patients had at one time or another hemodialysis grafts in all 4 extremities and none are to be used for access.
You elect to use glucagon to attempt in correcting the hypoglycemia. The patient blood glucose remains relatively unchanged. PT was secured to the cot. Cardiac monitor applied as well as pulse ox. She was loaded into the ambulance. While in route to the hospital you weigh your options between establishing a jugular IV or starting an IO. Your able to establish a jug stick and administer D50 after a few flushes ensure patency of the IV. PT become alert and oriented with a blood glucose level of 192.
Diabetes and hypertension are the top 2 predisposing factors for renal failure. Assessing a patient blood glucose level in a renal failure patient should be routine patient care. During the start of the pandemic I had a few runs with hypoglycemia patients at the dialysis center. The center changed its policy on patients eating during treatment. When in doubt, check the glucose level.
First and for most follow your local protocol on treating diabetics and administration of dextrose. D50, D25 and D10 all can be administered IO if protocol allows. While researching for this article I found it interesting the lack of studies on the efficacy in IO administration of dextrose in humans. The only study I found was in animals from 1988. (cited below)
Patient 2: You respond to a local dialysis center for a hypotensive patient. Upon arrival staff is stating the patient is new to dialysis. Staff says he was agitated for the 2 hours he had been receiving dialysis. The staff stated the patient’s last blood pressure was low. Once to the patient you find the unresponsive male patient in cardiac arrest. After CPR and 1 mg Epi IO your regain pulses. 12 lead shows an acute MI.
Enroute to the hospital a small fluid bolus fails to improve his blood pressure. A second IO is established after a failed IV attempt and lack of vascular access. the patient was administered dopamine. PT is transferred to the ED staff. While retrieving equipment the patient codes a second time. The physician order sodium bicarb and calcium chloride. The two medications were administered through the two different IO accesses. (Remember sodium bicarb and calcium chloride precipitate when mixed.) The patient regains pulses and is rushed to cath lab.
Patient 3: You arrive on scene to a lethargic female at home. The patient is a 63 year old female who receives hemodialysis three times a week. The patients family states the she is usually more responsive then this and had dialysis yesterday. Besides the renal failure, she has history of type 2 diabetes, hypertension and myocardial infarction 3 years ago.
Assessment reveals a heart rate of 108, respiratory rate of 22, A-fib on the cardiac monitor. Blood glucose of 181 and a temp of 102.2 axillary. Capnometer reading of 22 with a square waveform. Patients transferred the cot and loaded into the ambulance. Enroute you call in a sepsis alert to the receiving facility.
Hemodialysis provides a direct pathway for bacteria to the blood stream. Sepsis is very common among dialysis patients. Hyper or hypothermia with a ETCO2 less than 25mm/Hg is a strong predictor of sepsis in the prehospital setting.
Patient 4: You arrive to the local dialysis center for a patient with chest pain. PT was in his third our of a four hour treatment when he became short of breath and complained of chest pain. Treatment was stopped and the staff called 911. He now complains of substernal chest pain rated at a 4.
Patients heart rate of 110, O2 sat of 95%, BP of 138/94. 12 lead revealed controlled A-fib and left ventricular hypertrophy. IV established. The patient’s pain was relieved after baby asprin and nitro administration.
Chest pain as well as moments of hypotension and syncope are fairly common during dialysis sessions. Dialysis patients frequently end up with heart failure. The heart is constantly over pressured from fluid overload and when dialysis occurs preload is drastically reduced. Perform a 12 lead in all dialysis patients complaining of chest pain. Dialysis could almost be compared to a stress test on the heart at every session.
Syncope and hypotension occurs during dialysis due to a sudden lost of vasoconstriction during the session. These patients spend a lot of time overloaded with fluid. This over pressurizing of the baroreceptors is speculated to decrease the body’s autonomic response. Fluid boluses should be limited but may still be required to correct hypotension. (as always follow your local protocol)
Patient 5: Dispatched for a hemorrhage at the dialysis center. Upon arrival you find staff attempting to hold pressure on what looks like a horror scene from a movie. The nurse is covered in blood. They repeatedly attempted to control the bleeding for the last hour and a half. They stated the patient received a style of shunt and having trouble stopping the excessive bleeding.
When asked about using a tourniquet the staff stated it would not work with this style of graft. The blood was seeping through almost instantly every time it was replaced. While the staff swapped dressings arterial spray was noted.
Bleeding was controlled with a gloved finger and direct pressure to the site without gauze. The patient was transferred to the cot and secured. The patient was transported to the hospital. Upon arrival at the ER the patient’s nurse took over applying pressure with a gloved finger.
Excessive bleeding can be a common problem with dialysis patients. Many of the patients are on blood thinners as well as issues caused by repeated access to the site. Direct, firm pressure with a gloved fingers for a least 10 minutes should help resolve most bleeding. The pressure must be adequate enough to stop the bleeding at the graft and prevent bleeding in the subcutaneous tissues.
After consulting with Merit medical they felt the only way a light tourniquet may not have been effective at stopping the bleeding is if the graft is accessed improperly at the brachial anastamosis. (where it connects to the brachial artery) They also stated that in any emergency dealing with severe bleeding in dialysis patients (or any emergency for that matter) not to be fearful of damaging the graft, concentrate of saving life not limb.
Dialysis patients are some of the most chronically ill patients you come across. The treatment is hard on the body. My father was on dialysis before he died. He said ” They are sucking the life out of you. You feel completely drained afterwards.” These patients are under a constant daily struggle to maintain fluid restrictions and a normal quality of life.
References:
Steven R. Neish, MD; Michael G. Macon, MD; John W. M. Moore, MD; Intraosseous Infusion of Hypertonic Glucose and Dopamine. August 1988, https://jamanetwork.com/journals/jamapediatrics/article-abstract/514185
Gilbert Abou Dagher,Elie Harmouche,Elsy Jabbour,Rana Bachir,Dina Zebian, Ralphe Bou Chebl, 2015, Sepsis in hemodialysis patients https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606908/
Christopher L Hunter , Salvatore Silvestri , George Ralls, Amanda Stone, Ayanna Walker , Neal Mangalat, Linda Papa, March 2013 Comparing Quick Sequential Organ Failure Assessment Scores to End-tidal Carbon Dioxide as Mortality Predictors in Prehospital Patients with Suspected Sepsis. https://pubmed.ncbi.nlm.nih.gov/29760838/
R L Converse, Jr, T N Jacobsen, C M Jost, R D Toto, P A Grayburn, T M Obregon, F Fouad-Tarazi, R G Victor Nov 1992, Paradoxical withdrawal of reflex vasoconstriction as a cause of hemodialysis-induced hypotension. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC443221/